Propeller flap reconstruction of abdominal defects: Review of the literature and case report

The abdominal wall is perfused anteriorly by the superior and deep epigastric vessels with a smaller contribution from the superficial system. The lateral abdominal wall is perfused predominantly from perforators arising from the intercostal vessels. Reconstruction of soft tissue defects involving the abdomen presents a difficult challenge for reconstructive surgeons. Pedicle perforator propeller flaps can be used to reconstruct defects of the abdomen, and here we present a thorough review of the literature as well as a case illustrating the perforasome propeller flap concept. A patient underwent resection for dermatofibrosarcoma protuberans resulting in a large defect of the epigastric soft tissue. A propeller flap was designed based on a perforator arising from the superior deep epigastric vessels and was rotated 90° into the defect allowing primary closure of the donor site. The patient healed uneventfully and was without recurrent disease 37 months following reconstruction. Perforator propeller flaps can be used successfully in reconstruction of abdominal defects and should be incorporated into the armamentarium of reconstructive microsurgeons already facile with perforator dissections. © 2014 Wiley Periodicals, Inc. Microsurgery 35:72–78, 2015.     

Tumor implantation at the flap donor site: a case report

The genesis of cancer and its variable patterns of spread have been theorized and debated upon for decades. Recurrences, both local and metastatic, are dreaded by both the patient as well as the surgeon. An interesting case of tumor implantation at the flap donor site was noted in a patient who underwent a primary flap reconstruction for cancer of the cheek. The details of the case and theories regarding tumor implantation have been enumerated in this report.     

Radial forearm free flap donor site outcomes comparison by closure methods.

OBJECTIVE: To compare the functional and aesthetic outcomes of radial forearm free flap (RFFF) donor sites reconstructed with full-thickness skin graft (FTSG), split thickness skin graft (STSG) alone, and STSG overlying an acellular dermal matrix (AlloDerm). STUDY DESIGN AND SETTING: A cross-sectional cohort study at a tertiary care hospital. RESULTS: Twenty-five head and neck cancer patients who underwent reconstruction with RFFF completed the evaluations (STSG = 10, FTSG = 8, STSG with AlloDerm = 7). Subjective evaluations of postoperative function by questionnaires showed no significant differences among the 3 groups (P = 0.93). In blinded evaluations by surgeons, the STSG group obtained the highest aesthetic outcome score (3.39 of 5.0), followed by FTSG (2.89) and STSG with AlloDerm (2.80). However, the difference was not statistically significant (P = 0.32). Objective measurements of postoperative function by certified occupational therapists were comparable among the 3 groups with the exception of a mildly decreased range of wrist flexion (P = 0.036) and ulnar deviation (P = 0.016) in the FTSG group. CONCLUSIONS: The 3 methods of reconstruction have comparable postoperative functional and aesthetic outcomes. SIGNIFICANCE: Each of the 3 methods of reconstruction has low morbidity and satisfactory aesthetic and functional outcomes.     

Thoracoepigastric flap for the closure of an elbow defect in an intravenous drug abuser: A case report and review of literature

The reconstruction of large soft tissue defects of the upper extremity is a challenging problem. Although free tissue transfer in a single stage is preferred, the recipient blood vessels usually determine the outcome. Due to venous occlusion from repeated intravenous drug abuse, the use of a thoracoepigastric flap to cover a complex wound of the elbow is reported.     

A systematic review of anterolateral thigh flap donor site morbidity

PURPOSE:

The anterolateral thigh (ALT) flap is widely used in reconstruction. Its advantage over other flaps is its purported minimal donor site morbidity. The present systematic review summarizes the types of complications and their incidence with this flap. A secondary objective is to delineate factors that influence these complications and make recommendations to avoid them.

METHOD:

Two independent assessors undertook a systematic review of the literature using multiple databases. All patients with ALT flap reconstruction for any defect were included. Donor site complications including lateral thigh paresthesia, musculoskeletal dysfunction, hypertrophic scarring, wound breakdown, infection, donor site pain, seroma, hematoma, compartment syndrome and muscle necrosis were extracted from identified articles and tabulated. Based on the number of pooled events and the number of cases performed, an incidence rate was calculated.

RESULTS:

Forty-two relevant articles were identified that included 2324 flaps. Of the 2324 flaps, the majority were fasciocutaneous (n=737), and 1303 of the flaps were used in head and neck reconstruction. The incidence of complications were: lateral thigh paresthesia (24.0%); musculoskeletal dysfunction (4.8%); hypertrophic scarring or wound dehiscence (4.8%); donor site pain (3.3%); seroma (2.4%); infection (2.2%); hematoma (0.7%); compartment syndrome (0.09%); and partial muscle necrosis (0.09%).

CONCLUSION:

Lateral thigh paresthesia is the most common complication. Severe complications such as compartment syndrome and muscle necrosis can occur, but are rare. Preservation of the lateral cutaneous nerve of the thigh, femoral motor nerve branches and deep fascia decreases the risk of complications. The degree of vastus lateralis disruption did not show a significant impact on musculoskeletal dysfunction.     

Compartment syndrome after closure of the anterolateral thigh flap donor site: a report of two cases

Two male sarcoma patients developed a compartment syndrome in the thigh after the harvest and direct closure of the anterolateral thigh flap donor site. In each case, the absence of signs or symptoms led to a delay in diagnosis and treatment. Although use of the anterolateral thigh flap is increasingly popular for soft tissue reconstruction, this complication has not yet been reported. The cases and likely etiological factors are discussed as are recommendations for avoiding this devastating complication.     

辅助皮瓣法关闭下腹部供瓣区的临床应用体会

目的：总结直接关闭下腹部供瓣区的方法和体会。方法：25例病人手或前臂有软组织缺损创面，采用下腹部皮瓣转移的方法进行修复，同时设计邻接的辅助皮瓣参与下腹部皮瓣的关闭。结果：下腹部皮瓣和辅助皮瓣的供区直接缝合关闭，早期有不同程度的肚脐偏位，后期逐渐恢复。结论：辅助皮瓣法能较好地关闭一定面积的下腹部皮瓣供区，具有良好的整形美容效果。     

Supercharged dorsoulnar island flap: a case report and review of the literature

Complicated hand and wrist defects require durable and pliable tissues which are offered by flaps, instead of skin grafts. Various dorsoulnar flap options have been used in the regional flap armamentarium of the upper limb. Poor venous drainage may be a considerable handicap when moderate to large skin paddle dorsoulnar flaps are used. In the present case, we aimed to reduce the risk of necrosis by supercharging the dorsoulnar island flap. The current literature regarding dorsoulnar island flap has also been reviewed with focus on this flap. This technique has successfully been used for a complex wrist defect in a 48-year-old man. Postoperative follow up was one year. The flap survived completely with perfect hand function. We think this modification can prevent possible venous stress in the pedicled and free dorsoulnar flaps by obtaining extraveneous drainage. The method is simple, does not need sophisticated microsurgical procedure and longer operative time.     

Posteromedial thigh (PMT) propeller flap for perineoscrotal reconstruction: A case report

Fournier's gangrene can lead to extensive defects of the perineoscrotal area with exposure of the testes. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Due to its proximity, medial thigh skin appeared to be the most versatile donor site for perineoscrotal reconstruction. In this report, we present a case of reconstruction of a large perineoscrotal defect because of Fournier's gangrene using a posteromedial thigh (PMT) perforator propeller flap. A 58 year‐old male who suffered from Fournier's gangrene resulted in a scrotal defect of 10 × 12 cm² with a large dead space. A pedicled PMT propeller flap measuring 9 × 23 cm² with two perforators that originated from the profunda femoris artery (PFA) was harvested for scrotal defect reconstruction and dead space obliteration. The flap survived completely, with no recipient or donor site morbidity. The length of followup was 3 months and was uneventful. The pedicled PMT propeller flap may be considered as a valid option for perineoscrotal reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery 35:569–572, 2015.     

Internal mammary artery perforator propeller flap for contralateral mastectomy defect: A case report

The internal mammary artery perforator (IMAP) flap can be used as either loco‐regional or free flap, and provides thin flexible coverage for defects of the chest wall and cervical regions. In this report, we present a bilateral mastectomy case in which the left mastectomy defect was closed with an IMAP propeller flap harvested from the right breast. Our patient with a history of left breast conservation therapy was diagnosed invasive ductal carcinoma in her left breast 14 years later. On physical examination, the patient's left breast displayed the stigmata of radiotherapy including dark discoloration and firmness to palpation, compared to contralateral pendulous breast. After bilateral mastectomy, an IMAP flap with a size of 26 cm × 11 cm was harvested from right chest and was transposed 180 degrees clockwise in a propeller fashion to the left mastectomy defect without any tension. The flap survived without any complication and the patient was free of recurrence or metastases during the follow‐up of 18 months. The patient was satisfied with the outcome. IMAP propeller flap could be harvested safely to the anterior axillary fold in the subcutaneous fat plane. It may provide a large skin paddle especially in large breasted women. © 2016 Wiley Periodicals, Inc. Microsurgery 36:507–510, 2016.     

Gallbladder carcinosarcoma: A case report and literature review

Carcinosarcoma of the gallbladder is a rare malignancy characterized by both malignant epithelial and mesenchymal components. The clinical behavior of this tumor is extremely aggressive. Only 26 cases have been reported in the world literature to date. We report the case of a 64-year-old woman who had fever associated with a right upper quadrant mass. An exploratory laparotomy through a right upper quadrant incision was performed at another institution, and the patient was thought to have severe acute cholecystitis that would require additional antibiotic therapy before attempted resection. She was referred to our center, where abdominal CT showed a 6.4 x 8.2 cm pericholecystic mass involving the hepatic flexure of the colon. The patient underwent cholecystectomy and hepatic wedge resection, pancreaticoduodenectomy, and right hemicolectomy. Pathologic examination of the surgical specimen revealed two histologic components consisting of squamous cell carcinoma and spindle cell sarcoma of gallbladder origin, consistent with carcinosarcoma. All seven lymph nodes in the pancreaticoduodenectomy specimen were negative for tumor. We present this case and a review of the literature and current treatment recommendations.     

Testicular leiomyosarcoma: A case report and literature review

Introduction and importanceLeiomyosarcoma is a malignant mesenchymal tumor derived from the smooth muscle, it represents approximately 7% of all soft tissue sarcomas.Male genitourinary leiomyosarcomas are rare (Abdullazade et al., 2013 [1]).Primary testicular leiomyosarcoma is an exceptional entity with only 30 cases reported in the literature (Giridhar et al., 2011). Due to its rarity, additional studies are necessary to better define the optimal therapeutic management.Case presentationWe report a case of a 42-years-old male diagnosed in the urology department A of the University Hospital Ibn Sina in Rabat who complains of testicular swelling.The anatomopathological examination and immunohistochemical study revealed a leiomyosarcoma therefore, a radical inguinal orchiectomy with a primary ligation of the spermatic cord was performed for diagnostic and therapeutic purposes.The assessment of extension did not reveal any lymph node location or secondary appearance thus the decision of the multidisciplinary meeting opted for regular cancer check-ups without adjuvant treatment.DiscussionThe actual etiology of testicular leiomyosarcoma is still unknown added to its clinical presentation and radiological results that are non-specific.ConclusionLeiomyosarcoma of the testis is a very rare tumor and its clinical and radiological presentation remains similar to other testicular malignancies.     

Adult hepatoblastoma: A case report and literature review

INTRODUCTIONAdult hepatoblastoma is a rare malignant liver neoplasm. Surgery is the only cure, but recurrence is common even after complete resection. No therapeutic strategy has been established.PRESENTATION OF CASEA 22-year-old man presented with a rapidly expanding right hypochondrial mass. Pain preceded the appearance of the mass. No definitive diagnosis was established in the referring hospital. In addition, two attempts of embolization failed to reach the tumor due to its large size and vascular displacement. Clinical examination revealed a 26 cm × 23 cm mass occupying the right hypochondrium and epigastrium as far as the right iliac fossa, compressing the stomach, spleen, kidneys and liver. The preoperative diagnosis was gastrointestinal stromal tumor because it appeared to originate from the stomach. During surgery, we found a mass arising from the liver, adhering to the omentum, stomach, and left hemidiaphragm, and infiltrating the pericardium. The tumor was completely resected off the inferior vena cava and pericardium. The histopathological diagnosis was a 30 cm × 30 cm hepatoblastoma weighing 4 kg. The postoperative treatment course went smoothly until day 10, when the patient developed complications like bilateral atrial thrombi and left ventricular hypokinesia and expired on day 16.DISCUSSIONDue to the rarity of hepatoblastoma in adults and non-specific initial symptoms, hepatoblastoma is often overlooked as a diagnosis. Early detection may lead to improved prognosis and survival.CONCLUSIONWe report here the first case of adult hepatoblastoma in the Middle East and the largest such tumor ever reported in literature.     

Cerebral astroblastoma: A case report and review of literature

Astroblastomas are uncommon neuroepithelial tumors of uncertain origin. These occur predominantly in the cerebral hemisphere of young adults and children. They form only 0.45-2.8% of all neuroglial tumors. They can be easily misdiagnosed as they are rarely encountered in clinical practice and share common radiological and histopathologic appearance with other glial neoplasms. A 12-year-old female presented to us with progressive headache and diplopia. Her neurological examination showed right 6(th) nerve paresis with papilledema. Brain magnetic resonance imaging (MRI) revealed well-demarcated, peripherally enhancing solid cystic mass of 6 cm in right parietal lobe with mass effect. She underwent gross total resection of the lesion through right parietal craniotomy. The histopathologic diagnosis was suggestive of low-grade astroblastoma. The patient had no evidence of recurrence of tumor without adjuvant radiotherapy during the last 14 months of follow-up. Supratentorial astroblastomas are very rare tumors. Complete excision without radiotherapy is sufficient in low-grade variants.